Top Things to Know: Evidence Update for Minimally Invasive Surgical Evacuation of Supratentorial Spontaneous Intracerebral Hemorrhage
Updated: August 24, 2026
Prepared by Anne Leonard MPH, BSN, RN National Senior Director Science and Medicine
- Surgical management of intracerebral hemorrhage (ICH) has been limited due to concerns over procedural risks and a lack of functional improvement.
- Recent advancements in minimally invasive surgical techniques suggest potential improvements in functional recovery, broadening consideration for surgical treatment of certain populations, such as patients with lobar hemorrhage after spontaneous intracerebral hemorrhage.
- The ENRICH trial compared minimally invasive surgery (MIS) using tubular evacuation of ICH with modern medical management and found improved outcomes, primarily for lobar hemorrhages. A 6-month functional benefit was found.
- The MIND trial compared endoscopic evacuation and found high rates of technical success and safety, but with no significant reduction in mortality or improvement in functional outcomes at the 180-day end point. Exploratory analysis indicated improved clinical outcomes at 30 days with MIS for both lobar and deep hemorrhages.
- These two trials together suggest that selected patients may be considered good candidates for surgical intervention.
- Surgical techniques and goals for those techniques are described and discussed in this statement.
- This statement discusses how patients may be considered for MIS: patients presenting with lobar ICH between 30 and 80 mL with good premorbid neurologic status, National Institutes of Health Stroke Scale score >5, and Glasgow Coma Scale score >5 undergoing surgery within the first 24 hours.
- The statement offers a data-driven algorithm for acute medical management including the evidence-based bundled care: correction of any coagulopathy, blood pressure reduction, normothermia and normoglycemia (INTERACT3). The algorithm includes parameters for lobar ICH and deep ICH for potential candidacy for MIS.
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Gaps in knowledge are described in this advisory:
- Optimal timing of MIS intervention.
- Functional benefits of MIS still need to be demonstrated to establish superiority of any MIS technique.
- Outcome measures such as quality of life, cognitive status, and cost-effectiveness require further examination.
- Expanding trial eligibility criteria to capture a broader population (e.g., persons with large intraventricular hemorrhage).
- This science advisory provides a summary of the most current randomized evidence for minimally invasive surgical evacuation of ICH compared to medical management, and includes considerations for patient selection, care pathways, and surgical techniques.
Citation
Wolfe SQ, Amin-Hanjani S, Tschoe C, Simon SD, Kellner CP, Sheth KN; on behalf of the American Heart Association Stroke Council; and Council on Lifelong Congenital Heart Disease and Heart Health in the Young. Evidence update for minimally invasive surgical evacuation of supratentorial spontaneous intracerebral hemorrhage: a science advisory from the American Heart Association. Stroke. Published online August 24, 2026. doi: 10.1161/STR.0000000000000529